Suctioning an adult ICU patient: above cuff or subglottic suction

Recommendations for practice





Tracheal tubes with subglottic suction capability should be used for mechanically ventilated patients who are expected to be ventilated > 72hours.



If a tracheal tube does not have subglottic suction capability, a Y-catheter should be used to remove “above the cuff” secretions.


The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.

The mouth and oropharynx become colonised with pathogenic organisms after ICU admission. The main condition necessary for the development of ventilator-associated pneumonia (VAP) is the aspiration of small amounts (micro-aspiration) of secretions past the cuff of an endotracheal or tracheostomy tube. Factors such as impaired laryngeal function (e.g. trans-laryngeal tube), diminished upper airway reflexes, gastroesophageal dysfunction, passive regurgitation of gastric contents, continuous enteral feeding and supine body position are associated with the development of VAP (1).

A 2008 evidenced-based clinical practice guideline strongly recommended the use of subglottic secretion drainage when patients were expected to require mechanical ventilation for greater than 72 hours (2). This recommendation was based upon the review of five good quality studies and took into account the increased availability of tubes designed for subglottic suction. A recent systematic review and meta-analysis consistently supports the earlier recommendations. This meta-analysis included 13 randomised controlled trials of the effect of subglottic suction on the development of VAP and reported an overall risk ratio for subglottic suction versus standard care of 0.55 with no heterogeneity (3). This meta-analysis also suggested that subglottic secretion removal may be associated with reduced duration of mechanical ventilation and intensive care length of stay. In two randomised controlled trials, both continuous and intermittent subglottic secretion drainage have been associated with reduction of the incidence of VAP (4, 5). There is no evidence to support a recommendation regarding the method of subglottic secretion removal (continuous or intermittent).

Grading of recommendation taxonomy

Grade of recommendation



Body of evidence can be trusted to guide evidence


Body of evidence can be trusted to guide practice in most situations


Body of evidence provides some support for recommendation/s but care should be taken in its application


Body of evidence is weak and recommendation must be applied with caution


Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (6)


  1. Kallet RH, Quinn TE. The gastrointenstinal tract and ventilator-associated pneumonia. Respiratory Care. 2005;50:725-41.
  2. Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. Comprehensive evidence-based clinical practice guidelines fro ventilator-associated pneumonia: Prevention. Journal of Critical Care. 2008;23:126-37.
  3. Muscedere J, Rewa O, Mckechnie K, Jiang X, Laporta D, Heyland D. Subglottic secretion drainage for the prevention of ventilator associated pneumonia: a systematic review and meta-analysis. Critical Care Medicine. 2011;39(8):1985-91.
  4. Bouza E, Perez MJ, Munoz P, Rincon V, Barrio JM, Hortal J. Continuous aspiration of subglottic secretions (CASS) in the prevention of ventilator -associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134(5):938-46.
  5. Lacherade J-C, De Jonghe B, Guezennec P, Debbat K, Hayon J, Monsel A. Intermittent subglottic secretion drainage and ventilator-associated pneumonia: A multicentre trial. American Journal of Respiratory and Critical Care Medicine. 2010;182:910-7.
  6. NHMRC. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. 2009.


The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.